Sally Ellison

Dear Mr. Gittins, Rereport for the_ Prevention of Future_Deaths Inquest of Sally Ellison Following the conclusion of the above inquest you sent me report pursuant to Regulation 28 of the Coroners (Investigations) regulations 2013. In this Report you reported that the MATTERS OF CONCERN were as follows:- That urgent blood tests were requested by _ (GP) at lunchtime on 28th of April 2012, despite these noted as urgent; the samples were not conveyed to the laboratory for analysis after collection by the district nurse, until routine collection of samples was undertaken from Colwyn Bay Community Hospital later that afternoon. As a result the delay in analysis meant that results were not provided to surgery until the following morning: Whilst the evidence indicates that changes have been made within the laboratory at Glan Clwyd to enable the immediate reporting of all cases where the CRP is greater than 300, there was no evidence available to confirm that all urgent tests could be expedited by district nurses thus alleviating potentially life threatening delays in treatment: From this, you requested that actions should be taken to prevent future deaths. Because of the Pathology Clinical Programme Group (CPG) , and in particular the Governance section of the CPG, has reviewed the process for the requesting of urgent samples primary care across BCUHB. This process has explained in memorandum that will be distributed electronically to all GPs and Practice Managers supported by BCUHB. The memorandum includes the correct process for the labeling of samples and its transportation to minimise delay: It also includes the relevant departmental telephone numbers for the laboratories across North Wales to ensure that the sample requester can warn the relevant department of the samples imminent arrival: 27th the yet being have this, from been

Our colleagues in the Primary Care Support Unit will enable this distribution which will take place during the week commencing Monday June 2015. will write to you subsequently to confirm this distribution has taken place.